Transitional Training Guide Introductory Training for Mental Health Officers and Other Practitioners Trainers' Guide

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MENTAL HEALTH (CARE AND TREATMENT) (SCOTLAND) ACT 2003
TRANSITIONAL TRAINING MATERIALS

INTRODUCTORY TRAINING FOR MENTAL HEALTH OFFICERS AND OTHER PRACTITIONERS
TRAINERS' GUIDE

Annex A
To contain participants' notes from the exercise in Session 4.

Notes for the SCR on Karen:

The reasons behind the use of the powers to which the patient is currently subject.

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The views of the patient with respect to these current powers.

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The views of carers and family members on these powers.

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The patient's current state of mental health.

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The patient's mental health history.

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An assessment of risk to patient and any other person.

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The patient's detailed personal history, including employment, financial and accommodation situation.

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The patient's family situation, including children, dependants and caring responsibilities.

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The patient's regular social contacts: e.g. supportive friends, involvement with voluntary organisations, attendance of religious group etc.

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The patient's ability to care for himself.

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The care being provided to the patient prior to detention taking place.

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Any matters which could prompt the Local Authority to inquire under section 33 of the Act.

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The alternatives to detention which were considered and ruled out.

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The patient's history of detention, including any consideration of victims and/or those affected.

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The patient's history of substance misuse.

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The care planning which has been put into place to deal with any/all of the above issues.

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Any ethnic, cultural and religious factors which need to be taken into account.

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Any language or communication issues which need to be taken into account.

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Notes for the Compulsion Order Report on Karen:

The report should discuss:

The personal circumstances of the offender, views of relevant others (named person, carer and others):

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The MHO's views of the suitability of the measures being sought by the medical reports:

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A proposed care plan:

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Confirmation on behalf of the Local Authority of availability of community services that are to be delivered by compulsion:

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A description of any alternative mental health disposals that the Court may wish to consider.

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Annex B
THE MENTAL HEALTH (CARE & TREATMENT) (SCOTLAND) ACT 2003

TRANSITIONAL TRAINING MATERIAL EVALUATION FORM

Please rate the following statements by indicating with a cross on the scale from 1 to 10, where 1 is 'not at all' and 10 is 'extremely well':

about the readers

The case studies

Course design

course facilitation

Annex C
Alternative/Additional Case Study:

Reflecting on a CTO and the Principles in Relation to an Advanced Statement:

As discussed in the text of the Trainers' Guide, we want to propose something more complicated, challenging and imponderable in this alternative case study. The specific purpose of this exercise is to get you to think about the conditions for a CTO in relation to the process of making an application. While it will inevitably be relevant to discuss the timing of the medical reports in relation to the MHOs report and the proposed care plan, we do not wish you to get too hung-up on the mechanics of the process. The aspects of the process we wish you to become more concerned with in your discussion are how the principles relate to the conditions for a CTO and how this articulates with the complicating factor of the advanced statement. In doing this, it may also be relevant to consider the broader Human Rights underpinned by the principles, especially Article 10 of the European Convention: the right to freedom of expression. This underpins our right to hold and express political views.

We also wish you to consider the potential for airing differences of opinion in the process of application and the ways in which those opinions may be expressed in the reports.

For many years Mark Freeman has been an active figure in the Animal Liberation Front, an established national animal rights group. He has been involved in numerous demonstrations and direct action protests and he has been arrested on several occasions in relation to his cause. He works tirelessly for his local group and the cause is central to Mark's life. For all of his adult life Mark has been a vegan vegetarian to the full extent of not eating, using or wearing any animal products or products derived from testing on animals.

Mark has a ten yearlong history of bipolar affective disorder. He has a good understanding of the illness and the ways in which it has hampered his life in the past. He has developed many life skills as means of self-management of the disorder. While never liking the treatment, having a good relationship with his psychiatrist and the help of sound maintenance regime of medication, Mark has managed to keep free from any manifestation of his illness for three years now. However, while Mark was coming to terms with his illness, or in his words, while he was still learning the lessons it taught him, he was detained under the 1984 Act on two occasions.

Mark has recently discontinued his medication as he believes it to be derived from a process of animal testing. He has ordered his own supply of Tranquilibrium over the internet. Tranquilibrium is a form of Lithium that Natural Resort plc, the manufacturers claim is 'non-synthesised, naturally occurring and incurring no harm to animals in its production or manufacture. ' However the result of this disruption in treatment is a resurgence of hypomania such that Mark seemed to be behaving in ways that posed risks to health and welfare and potentially to his safety. His sleep pattern had become progressively more erratic. During this time Mark had been energetically pursuing numerous plans and ideas, all of which he left in a half completed trail of chaos. Some of these ideas have taxed his slender income to the limit. For example, on a whim he determined that local wildlife was being damaged by the use of agricultural chemicals. He purchased an expensive metal cage and a flight to London, with the intention of collecting hundreds of specimens of wildlife, the idea being that he would release them in Downing Street. He did not collect and animals and he missed the flight because he had to attend a meeting of his local Animal Liberation group, at which he alienated many of his friends by suggesting that they should publicly torture a dog to show people how much animals suffer in laboratory experiments.

Mark was detained in hospital under a short-term certificate, granted by his RMO and consented to by an MHO. However, Mark has a properly authorised advance statement registering his wish that, should he ever require treatment by compulsion, nothing should be given to him that would cause, or have ever caused harm animals. In this he specified two matters in particular: his diet and his medication. In the first few days of Detention Mark did accept some treatment to alleviate his acute symptoms. However now, ten days into the 28:day period of the Short-term Detention, he is refusing to take any form of prescribed medication and because of his hypomania, his management is posing nursing staff considerable problems. Mark has a named person, his partner David. His advanced statement emphasises that David should be a full party to discussions about treatment matters. While less radically committed to the cause, David does share Mark's concerns for animal liberation. He is supportive of Mark's refusal, even though nursing staff have advised him of the risks to Mark's mental and physical wellbeing, should his hypomania go untreated. In turn David points out that, while fully competent to make such decisions, Mark has taken considerable risks in support of his cause in the past, including getting himself arrested. Why should his choice to do so now be denied him just because he is mentally ill?

Even though the RMO has read up all she could find on the internet about Tranquilibrium (Mark's preferred choice of treatment), her clinical opinion is that too little is known about the efficacy of the product. It also seems extremely unlikely that any form of maintenance medication would be effective in this crisis situation where the intervention of a major tranquilliser seems to be urgently indicated.

Questions for discussion:

In keeping with the complexity of the case study we intend to ask you some difficult questions. The overall point of this exercise is to consider the merits of making an application for CTO against the options of allowing Mark to remain untreated under the Short-term Detention or the merits of using the Short-term Detention to enforce treatment against the wishes expressed in the advance statement.

1) In considering this complicated problem it will be necessary to ask whether Mark's current circumstances fulfil the conditions set out in section 57 (3)?

In answering this, guidance may be obtained from the broad human rights perspective and the specific principles of the Act. Therefore, having asked you to satisfy yourself that the conditions may be met in this situation, we ask you to refine your thinking against the following:

2) Given that Mark's right of freedom to express his political opinions through refusal of medication is not an absolute right (it is, for example restricted by laws relating to civil order), how do you balance it with Mark's right to receive care, protection and treatment when unwell?

You may discern that there are two very different perspectives on this rights issue. One is expressed by Mark's partner. It may be summed up in the following quote from the case study 'He is supportive of Mark's refusal, even though nursing staff have advised him of the risks to Mark's mental and physical wellbeing, should his hypomania go untreated. In turn David points out that, while fully competent to make such decisions, Mark has taken considerable risks in support of his cause in the past, including getting himself arrested. Why should his choice to do so now be denied him just because he is mentally ill?'

The other perspective is implicit in the nursing staff's concern for Marks wellbeing, regardless of his past wishes. This perspective assumes that Mark's wishes are invalidated by the seriousness of the risks he is facing.

While recognising the validity of both sides, it is difficult to reconcile them. We suggest that some practitioners are more likely to be oriented towards treatment by compulsion, knowing the risks of allowing someone's mania to go untreated. This perspective would uphold the person's right to receive treatment when too ill to recognise the need for it. On the other hand, while other professionals may not be comfortable accepting the gravity of risks in allowing Mark to remain untreated, they would uphold Mark's right to freedom of choice as a right that he is even entitled to die for.

3) What problems may be posed in making an application where the RMO and MHO hold such irreconcilable views?

Drawing from the Principles of the Act, consider:

What is the importance of Mark participating as fully as possible in the discharge of the function? (The here function is to arrive at a decision about how best to resolve the treatment question.)
How may 'benefit' be interpreted in Mark's case, in respect of the 'importance of providing the maximum benefit to the patient'?
How can this function be discharged in a manner that involves the minimum restriction on Mark's freedom that appears to be necessary in the circumstances?

4) What benefits do you perceive in the Tribunal's role in determining this application?

This pack is one of a series of Training Guides detailed below developed for local authority mental health officers and related health and social care staff commissioned from Robert Gordon University by the Scottish Executive.

Reader 1
Introductory training for mental health officers and other practitioners

Reader 2
Emergency and short-term detention and related matters

Reader 3
Compulsory treatment orders and related matters

Reader 4
Provision of social circumstance reports and provisions for people with mental disorder within the criminal justice system and other related matters

Trainers Guide for Readers 1-4

Briefing Paper
For health service and local authority managers

Briefing Paper
For local authority elected members

This material is also available on the Scottish Executive's mental health law website
www.scotland.gov.uk/health/mentalhealthlaw

Footnotes

The sample answers from this process are set out in this guide.
Note that we have placed a statement at the end of each reader advising participants to read and reflect upon the case studies if they have spare guided study time.
Report of the Inspection of Scottish Borders Council Social Work Services for People with Learning Disabilities, SWSI, April 2004 and Joint Statement from the Mental Welfare Commission and the Social Work Services Inspectorate, SWSI, April 2004.
In reality it would be most likely that the Assessment Order would be replaced by a Treatment Order upon expiry of the 28 days, before Karen approached the sentencing diet of the Court.

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